Is the ER supposed to stablize the Patient before transferring to the unit?

Dalzac, LPN, LVN, RN · Apr 20, 2005

I found out a long time ago when I used to work in ER that some ER's wil transfer unstable nearly dead patients to keep their mortality rates low. Sad but true

RainbowSkye · Apr 20, 2005

Well, gee, that hasn't been my experience at all (sending nearly dead patients to the floor or unit). As a matter of fact, if death seems imminent and there is nothing that can be done, we keep them in the ER to avoid having someone go upstairs and die in 5 minutes. And that's pretty much been the policy in every ER I've worked.

As for the tylenol OD who is now brain dead, there certainly was something else going on there. That is certainly not the usual pattern of events where tylenlol is the only drug - I'm thinking maybe something was missed there (like a drug screen to identify what drugs were actually ingested).

Do you work in the ICU? Because if you do, you will certainly get unstable patients from the ER. Our job is to attempt to identify what's going on, and begin life saving interventions; your job is to take if from there. If however, you work on a medical floor, this patient should have never been admitted to you.

My two cents.

Mellow Yellow · Apr 20, 2005

You did not say what kind of a unit you work in but by mentioning ACLS my guess you receive critical patients. As far as the ED not sending you stabled patients, in my humble opinion that is exactly what they did send you, clinically stable patients that needed your further help on your specialized unit.

Your patients had the A B C's. There was (A) an open working airway and the patient was (B) breathing on their own. and © had a blood pressure, 68 systolic is nothing to write home about but circulation was working. The Emergency Department did their job and they transferred them to you, the next link in the chain to get them well. This is Critical Care Nursing and there are no promises the IV will be patent after transfer. From the information you have given in your post, your unit is the correct place for them to be. They don't regulate dopamine drips on the floor or send patients who potentially needed intra aortic balloon pumps for Bi ventricular failure to the floor. My impression, you might want to think about your assignment and if this is the place you want to spend your time as a nurse, ask for a transfer. I wish you all the best and please keep this thought in mind, your patients really need you no matter where you are assigned.

I have had 2 scarey situations 2 nights in a row. The first night an Acetominophen overdose was sent up with just a saline lock, when we took her first b/p it was 68 systolic, got an order to bolus her and the iv didnt' work, got worse from there, we think she is now brain dead. The next night I got report for a patient with COPD and biventricular failure with a pulse in the 160's and a sys of 80 on a dopa gtt at 5 mcgs. I called the supervisor about them stabilizing the patient before transferring them up and was told that was not their job. I know of another night were a patient was sent up who was in 3rd degree HB wasn't paced nothing, and this was an extra patient for them so their resources were spread very thin. According to ACLS protocol, these symptoms should be treated when the present themselves. Does anyone have any experience to the contrary?

indapinda · Apr 20, 2005

I think the point is being missed here, and I agree about the ER wanting to keep their death rate stats down, because I have recieved dead patients. But the point here is the heart rate in the 160's.... I guess if it can be missed here, it demonstrates how it was missed in the ER.

Mellow Yellow · Apr 20, 2005

What about a heart rate of 160? It is not a lethal arrythmia, most likely a rapid atrial fib. Dollars to donuts the doctor wrote orders to help treat the underlying cause. I do not want to argue and I will not. These are the patients who are admitted to a hospital from the ER which in these days and times is not something easy to happen because insurance refuses to pay unless a patient is in this kind of condition. It can take up to 3 days to slow this heart rate and it is everyday care on a monitored unit. Talk to your immediate supervisor. It sounds like much more is bothering you.

I think the point is being missed here, and I agree about the ER wanting to keep their death rate stats down, because I have recieved dead patients. But the point here is the heart rate in the 160's.... I guess if it can be missed here, it demonstrates how it was missed in the ER.

Trauma Columnist · Apr 20, 2005

I may be missing the point here too. However, at least in my ER (level one, large teaching institution), we don't even keep stats as to deaths in the ER versus the other parts of the hospital. Also, I have sent patients to the ICU's without having them stabilized. My job in the ER is to resuscitate, stabilize when able and ship them upstairs where more definitive care can be instituted.

tiredfeetED · Apr 20, 2005

I found out a long time ago when I used to work in ER that some ER's wil transfer unstable nearly dead patients to keep their mortality rates low. Sad but true[/quote
I have never heard of this...I dont think we even keep track of the mortality rates....Our issue in the ED is that the ICU wants us have the patient stable. So we keep pt till pressors have been titrated for a decent BP which isnt bad. I have been told tho by our ICU several times that the patient is to critical for the unit and we must stabilze before transfer. What ever is better for the patient, I have docs trying to send a pt upstairs with a bp in the 90's with 24 guage and no other chance for access. We dont leave till they put a triple in.

snowfreeze, BSN, RN · Apr 20, 2005

I worked in ICU for a number of years and many unstable patients arrived there from the ER or direct admit from our helipad. ER determines problem, initiates treatment then determines what is the best place for the patient to go. A good report might help you more in knowing that you will need to initiate a central line upon arrival and possibly intubate soon. If you are receiving these critical patients on a telemetry unit or a med/surg unit..run quickly and find another job.

PJMommy · Apr 20, 2005

I'm afraid I'm going to have to agree with the others. I work ICU and frequently get pt's who are very unstable. Sometimes...it's pretty iffy whether or not a pt is ever going to be stable so might as well get them to a critical care unit where we can do 1:1 nursing and start additional interventions.

The part about receiving dead pts surprised me at first...but then I realized we get them all the time from ER -- the brain dead pt. But the ICU is going to take care of getting an EEG done, doing apnea tests -- and having the pt declared. And if this pt is an organ donor, ICU nurses will work with the recovery team to run labs, do additional testing, etc. in order to place organs and work with the surgical team to prep the pt for OR.

indapinda, do you work in critical care or are you on a med/surg floor? Our responses would be a lot different if you are on a med/surg unit without the support and tools to deal with the very unstable pt.

mattsmom81 · Apr 20, 2005

If patients are routinely sent to medsurg units unstable, I would suggest writing incident reports, bringing this to the attention of managers to investigate what the problem is. Is it being done intentionally? Is ER staff not catching a change? Or is the doc not getting updated reports of condition from the staff, etc.

Every once in awhile something can slip past, but when it becomes an accepted practice it needs to be dealt with IMHO.

CHATSDALE · Apr 20, 2005

I have worked med-surg where we got some highly unstable patients but there was usually a reason...no room in icu and triage send them out of er because they needed the room for mi or mva etc

er should stablize if at all possible because when they get to floor if you have a poor report [depending on er nurse, can be comprehensive or a lick and a promise] you may be tied up in a equal emergency and not have the personnel to take care of both at once